Category Archives: Most Wanted List

Oshkosh AirVenture 2019: Raise the Bar of Your Safety Culture

By Aaron Sauer, NTSB Senior Air Safety Investigator, and Amy Terrone, NTSB Safety Advocate

Loss of control and midair accidents, drones in accident investigations, startle effects and distraction, general aviation safety trends, and survivor stories (oh my!)—these are just a few of the topics NTSB staff will present at this year’s Experimental Aircraft Association AirVenture in Oshkosh, Wisconsin. The goal of our presentations is to encourage every aviator and aviation professional to raise the bar of their safety culture.

Safety culture comprises an organization’s attitudes, beliefs, behaviors, and values regarding safety. It’s an idea with its roots in the safety of organizations; however, pilots have their own unique safety culture, as well, exchanging information informally about aircraft characteristics, avionics, and even en-route concerns, such as weather and notices to airmen (NOTAMs), that might affect a flight.

In fact, every organization has a culture, but not all culture is related to a formal organization. We are interested in helping pilots raise the safety culture bar within the broader aviation community. That’s why nearly 20 NTSB investigators, vehicle recorder specialists, safety advocates, and even the NTSB’s own Chairman Robert Sumwalt will be walking the AirVenture grounds daily July 22–28, sharing insights and learning from others.

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AirVenture is billed as the largest annual gathering of aviation enthusiasts in the United States, and maybe even the world. One week each summer, more than 500,000 EAA members, aviation enthusiasts, and pilots from 80 countries come to Wittman Regional Airport in Oshkosh. Attendees watch air shows and aerobatics and pyrotechnics displays, and attend educational forums, workshops, and demonstrations. In addition to those in the aviation industry, the event also draws members of the general public interested in aviation.

We’ve maintained an exhibit booth and delivered informative presentations at AirVenture for the past 15 years. In addition to presenting, NTSB investigators are always on hand to begin the on‑scene phase of an investigation if needed, because, unfortunately, at least one or two accidents occur each year as aircraft fly into the event. In fact, these fly-in accidents have led us to publish a safety alert urging pilots to keep their focus on safety while arriving at a major fly-in event like AirVenture, where there are more planes in the parking lot than cars.

This year we’ve asked some of the industry’s leading safety experts and those with unique insights to help us spread our safety culture message.

We’ll work with Patty Wagstaff, a legendary acrobatic pilot, to kick off the first day of the event with a discussion about what it means to “Raise the Bar of Your Safety Culture with Challenging Training.” Tim LeBaron, the deputy director for the NTSB Office of Aviation Safety Regional Operations, will introduce Wagstaff and offer preliminary comments on this issue.

The rest of the week will be filled with opportunities to learn more about how pilots can play their part in building a stronger safety culture. Staff will present several accident case studies that highlight pilot errors, lack of proficiency, and decisions that led to loss of control in flight. They will include a case study of a Teterboro, New Jersey, crash that illustrates our new Most Wanted List (MWL) issue area, “Improve the Safety of Part 135 Aircraft Flight Operations.”

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We will also talk about weather challenges—a significant concern in general aviation flying—and how to manage and overcome a variety of scenarios, and we’ll share several safety alerts related to weather. Our research team will present general aviation safety trends and new statistics, and we’ll discuss distraction, a long-time MWL issue that is dramatically affected by the proliferation of technology in the cockpit.

But perhaps the most important presentations we will give are the ones that remind us of why we do what we do—that is, issue safety recommendations to prevent accidents and crashes.

We’ve also teamed up with two accident survivors to help drive our message home. These speakers will share their harrowing stories in the hopes that they can motivate other pilots to avoid the same mistakes. Dan Bass will offer the riveting story of how he survived an in-flight loss of consciousness due to a carbon monoxide leak, a serious safety concern that has prompted us to release several safety alerts on the topic. Trent Palmer and Nikk Audenried will share their story about a loss-of-control accident they experienced that was widely shared via YouTube. Preventing loss of control in flight has been featured on the NTSB MWL for several years.

If you’re attending AirVenture, plan to visit our booth in Exhibit Hangar D in the Federal Pavilion to meet investigators, touch a real-life “black box” (actually orange), and learn about our most important general aviation safety issues and our current MWL. You’ll likely find the Chairman engaging with pilots around our booth, and you can tune into EAA radio during the week for some of his key general aviation safety insights. We would certainly like to see you join us for our presentations and you can plan your itinerary by visiting https://www.ntsb.gov/news/events/Pages/2019-EAA-AirVenture-EVT.aspx.

Even if you can’t make it to AirVenture 2019, rest assured that we’re using opportunities like AirVenture throughout the year to encourage general aviation aviators and aviation professionals to raise the bar when it comes to safety.

Don’t Drive High This 4th of July

By Leah Walton, NTSB Safety Advocate

When I started my career with Mothers Against Drunk Driving 20 years ago, I never imagined I would still be advocating to eliminate impaired driving in 2019. I wasn’t so naïve to believe we’d have flying cars by now, but I did think that, surely in 20 years, Americans would shift their attitudes and behaviors to routinely separate drinking and driving. After all, impaired driving is 100% preventable with smart choices and planning for a sober ride home.

We should have zero fatalities when it comes to impaired driving, and yet, the National Highway Traffic Safety Administration (NHTSA) reports that over 10,000 people die in alcohol-impaired driving crashes every year. That means one-third of all traffic fatalities are caused by impaired driving. What’s more, those numbers are limited to alcohol impairment at the 0.08-percent BAC level or higher. If we include all alcohol-involved fatalities, that statistic increases to over 12,000.

As if that number wasn’t bad enough, it doesn’t even include other drug-impaired driving. We don’t have accurate statistics for those yet because there’s currently no common standard of practice for drug toxicology testing (although NHTSA is making progress toward implementing this NTSB recommendation).

Impairment is impairment, regardless of if someone is impaired by alcohol, marijuana (for recreational or medical use), illicit drugs, or even prescription or over-the-counter medications.

Instead of seeing that attitude and behavior shift I had hoped for years ago, today, an estimated 14.8 million drivers report that, in the past 30 days, they got behind the wheel within 1 hour after using marijuana, according to a recent AAA Foundation for Traffic Safety survey. The AAA survey also revealed that 70% of Americans think it’s unlikely a driver will get caught by police for driving while high on marijuana. Those folks are in for a sad surprise, as more law enforcement officers are being trained in the Advanced Roadside Impaired Driving Enforcement (ARIDE) and the Drug Evaluation and Classification (DEC) programs, and many are being certified as drug recognition experts (DREs). This means traffic officers have been specifically trained to detect and identify impairment—by alcohol or other drugs—with a high level of accuracy.

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The 4th of July is one of the deadliest holiday periods of the year when it comes to impaired-driving crashes. But it doesn’t have to be. Drive sober. Choose—or volunteer to be—a designated driver. Use a ride-sharing app or public transportation. There’s never an excuse to drive impaired by alcohol or other drugs. Don’t drive high this 4th of July.

Deadly Days of Summer

By Stephanie Shaw, NTSB Safety Advocate

My youngest son is 16 and a newly licensed driver. He’s had his license for about 4 months. Statistically, as a driver, the cards are stacked against him. For young drivers like him, the first 6 months of unsupervised driving are the most dangerous. As a mom, I’m terrified.

Memorial Day marked the beginning of the “100 Deadliest Days” for young drivers. All parents should know that during this driving season, crashes involving 16- to 19-year-olds spike more than among any other age group. Per mile driven, our teens are nearly three times more likely than other drivers to be in a fatal crash.

For seven summers now, the “100 deadliest days” have been the “100 scariest days” for me, only lessening slightly as my older son entered his 20s. Now my younger son is a newly licensed driver and the terror is freshly upon me again.

And I’m not alone. Just as many students revel in summer freedoms, throw themselves into summer jobs, take trips away from home, and celebrate life late into some nights, their parents worry over their safety.

Don’t get me wrong. My sons are, overall, good young drivers. But during the 100 Deadliest Days, young drivers are getting behind the wheel with cellphones in hand, or drowsy from long summer nights. And they are spending more time behind the wheel. A recent AAA study found that each year over a recent 5-year period, an average of 1,022 people died in crashes involving teen drivers during the 100 Deadliest Days.

What makes driving during this time of year so deadly for teens? Mostly lack of experience.

Help your teens gain experience by taking them out for drives not just on sunny days, but in the rain and, in a few months, the snow. Allow them to experience driving in heavy traffic conditions, merging, and making left turns.

Parents, I know it’s scary, but rest assured, you’re doing the safe thing. Students have to learn by doing, and the best way to do that is with a responsible adult driver next to them. And note: that doesn’t mean they should go out driving with a slightly older teen! Teen passengers significantly increase a teen driver’s risk of being in a crash. Teen drivers should not carry passengers under age 21—not their friends, and not their siblings or other young family members.

My sons know that I live for those moments when they bring up road safety. (That’s one hazard of having a mom who works for the NTSB!) Although I only started emphasizing safe driving behaviors once my sons learned to drive, I’ve not been shy about sharing them since.

Fellow parents, it’s our responsibility to talk to our young drivers about avoiding distracting activities, like talking on a cell phone, texting, posting on social media, skipping a song on their playlist, or trying to use navigation apps, while driving. And of course, it’s our responsibility to remind them to always buckle up! Most importantly, we need to demonstrate safe driving habits ourselves. Don’t just give good advice—set a good example.

I’m proud of how often I see my sons doing the little things right (although as a mom, I’ll always worry). I know I’m not alone in this, either. I’m confident that other parents are proud of their kids’ safe driving progress too, even if it seems they only notice the little things their student driver is doing wrong.

6 Rules Parents_Graphic-Banners-300x250This summer talk with the young people in your life about safe driving and the hazards they’ll be up against over the next 100 days. Doing so will ensure that they have many thousands of days ahead.

 

Remember Bellingham

By Member Jennifer Homendy

Today marks the 20th anniversary of the Olympic Pipe Line rupture in Bellingham, Washington, which resulted in the release of about 237,000 gallons of gasoline into a creek that flowed through Whatcom Falls Park. Sometime after the rupture, the gasoline ignited and burned about 1.5 miles along the creek. Two 10-year-old boys and an 18-year-old young man named Liam Wood died; 8 others were injured.

Bellingham, WA
Postaccident aerial view of portion of Whatcom Creek showing fire damage.

Liam had just graduated from high school and was fly fishing when he was overcome with fumes from the rupture. Years later, I met Liam’s stepfather, Bruce Brabec, as a staffer on Capitol Hill. Since Liam’s death, Bruce has been a tireless advocate for closing gaping holes in pipeline safety regulations, many of which have been revealed as a result of our pipeline accident investigations.

This past fall, I saw Bruce at a pipeline safety conference. The discussions over the days that followed left me wondering how much we’ve accomplished over the last 20 years. Is our pipeline system truly safer?

From a numbers standpoint, it’s good news and bad news. According to the Pipeline and Hazardous Materials Safety Administration (PHMSA), there were 275 significant gas and hazardous liquid pipeline incidents in 1999, resulting in 22 fatalities and 208 injuries. Since that time, the number of significant incidents has fluctuated as PHMSA adopted new reporting criteria, with 288 significant incidents occurring in 2018.

Fatalities and injuries have decreased since 1999 to 7 fatalities and 92 injuries in 2018, but that provides no comfort for victims, their families, or their loved ones. The fact is, although pipelines are one of the safest ways to transport hazardous material, the impact of just one incident can be devastating. And although the number of accidents is low compared to other modes like highway and rail, there is much more that pipeline operators and federal regulators can do to get to zero incidents, zero fatalities, and zero injuries on our nation’s pipeline system.

Our recommendation for operators to install automatic or remote-control shut-off valves in high‑consequence areas is a perfect example. In 1994, we investigated a natural gas transmission pipeline rupture in Edison, New Jersey, which resulted in a fire that injured 112 people and destroyed 8 buildings. Pipeline operators were unable to shut down the gas flow to the rupture for 2½ hours. Our report on the accident recommended that the Research and Special Programs Administration (RSPA), PHMSA’s predecessor, expedite requirements that automatic- or remote‑operated mainline valves be installed on high-pressure pipelines in urban and environmentally sensitive areas so that failed pipeline segments can be rapidly shut down. We have been recommending valve installation in some form on pipelines since 1971.

In response, RSPA issued a regulation requiring operators to install a valve only if the operator determines it will efficiently protect a high-consequence area in the event of a gas release.

Fast forward to September 9, 2010, when an intrastate natural gas transmission pipeline owned and operated by the Pacific Gas and Electric Company ruptured in a residential area in San Bruno, California. The rupture produced a crater about 72 feet long by 26 feet wide. The section of pipe that ruptured was found 100 feet south of the crater. The released natural gas ignited, resulting in a fire that destroyed 38 homes and damaged 70. Eight people were killed, many were injured, and many more were evacuated from the area.

In our report on the accident, we once again recommended that PHMSA expedite the installation of automatic shutoff valves and remote-control valves on transmission lines in populated areas, drinking water sources, and unusually sensitive ecological resources. Congress then required PHMSA to implement the recommendation in the Pipeline Safety, Regulatory Certainty, and Job Creation Act of 2011 (PL 112-90).

It’s been a decade since San Bruno, and PHMSA is nowhere near issuing a final rule to implement our recommendation. This issue is highlighted on our 2019–2020 Most Wanted List of transportation safety improvements (Ensure the Safe Shipment of Hazardous Materials).

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It’s my hope that over the next few years, we’ll see some real improvements in pipeline safety and avoid tragedies like the ones in Bellingham and San Bruno. With the technology we have readily available today, there’s absolutely no reason for any parent to have to face the loss of a child because of a pipeline accident. I hope that the next time I see Bruce Brabec, we’ll finally have the regulations in place that he’s worked so hard for on Liam’s behalf.

 

 

 

 

The Golden Spike at 150

By Member Jennifer Homendy

The ceremony for the driving of the golden spike at Promontory Summit, Utah on May 10, 1869; completion of the First Transcontinental Railroad. At center left, Samuel S. Montague, Central Pacific Railroad, shakes hands with Grenville M. Dodge, Union Pacific Railroad (center right). (Source: Wikimedia)

On May 10, 1869, 150 years ago today, a golden spike was driven home at Promontory Summit, in what was then the Utah Territory, by Central Pacific Railroad President Leland Stanford. This momentous event joined the Central Pacific and Union Pacific Railroads, completing the first transcontinental railroad, just 7 years after President Abraham Lincoln signed the Pacific Railway Act authorizing land grants and government financing to US railroads for the purpose of joining the east and the west.

As we know, the project was a tremendous success, but it certainly had its challenges.

In 1863, another act established the gauge for the project at 4 ft., 8½ inches (which became the standard gauge). At the time, gauges varied among railways in the United States. The goal of the transcontinental railroad was to ensure that two railroads met in Utah and were “interoperable” when it came time to begin service. A small difference in width would mean no transcontinental railroad: passengers and freight would have to be offloaded to a new train when incompatible rails met, creating a bottleneck affecting thousands of miles of track.

It wouldn’t have inspired confidence in the transcontinental railroad if the four final spikes couldn’t be driven in because the railroad gauges didn’t match!

Leland Stanford, the man who drove the golden spike, went on to found Stanford University. He could not imagine the contributions to transportation that his namesake university would make, including those to the global positioning system used in positive train control (PTC) systems.

Just as the Central Pacific and Union Pacific Railroads worked to ensure their track was seamless, today’s railroads are focused on implementing PTC by ensuring interoperability among many systems­—passenger, commuter, and freight trains must be able to seamlessly communicate and operate across all railroad networks.

PTC isn’t new. The NTSB has been urging railroads to implement it, in some form, since 1970, 1 year after the United States met President John F. Kennedy’s challenge to land a man on the moon. Since then, the NTSB has investigated 152 PTC-preventable accidents that resulted in more than 300 fatalities and 6,700 injuries. PTC remains on our Most Wanted List of transportation safety improvements.

Seven years passed between when Lincoln signed the Pacific Railway Act in 1862 to when the golden spike was driven home at Promontory Summit. Eight years passed from JFK’s speech to Congress about a moonshot in 1961 to Neil Armstrong’s first steps on the gray dust of the lunar surface. PTC was mandated by Congress in the Rail Safety Improvement Act of 2008. It has now been more than 10 years since the act was signed into law.

Today’s golden spike celebration might well feature photos of two locomotives posed head-to-head, as they were for the original golden spike celebration 150 years ago. Perhaps that would also be a fitting image to promote PTC, which, among other safety benefits, would automatically stop trains in time to prevent train-to-train collisions.

As we commemorate 1869’s golden spike, the NTSB continues to await implementation of fully operational PTC, which is long overdue. Let’s end the wait and start planning our own commemoration of the day we finally made all rail travel exponentially safer.

 

Global Road Safety Week

By Nicholas Worrell, Chief, Safety Advocacy Division

Around the world, about 1.25 million people lose their lives every year in motor vehicle crashes. That’s roughly the entire population of Dallas, Texas. Others—20–50 million—are injured or disabled. That’s about the equivalent of injuring everybody in a medium-sized country, like Spain (46 million) or Ukraine (44 million).

May is Global Youth Traffic Safety Month (GYTSM), and May 6–12, 2019, marks the Fifth United Nations Global Road Safety Week. These events draw attention to the need for stronger road safety leadership to help achieve a set of global goals. International governments have set an ambitious goal to reduce by half the number of deaths and injuries from road traffic accidents globally by 2020.

On behalf of the NTSB, during this GYTSM, I’ll join with advocates and road safety experts from around the world to launch action through the ongoing campaign “Save Lives—#SpeakUp.” The campaign “provides an opportunity for civil society to generate demands for strong leadership for road safety, especially around concrete, evidence‑based interventions.” From May 8 to 10, I’ll also have the opportunity to speak to an audience of public transportation agencies from throughout the Caribbean region, as well as road transportation professionals and academics from around the world, at the 8th annual Caribbean Regional Congress of the International Road Federation in Georgetown, Guyana. As a Caribbean native, I am especially looking forward to discussing the NTSB’s lessons learned, recommendations, and advocacy efforts with professionals there.

One of the big messages I hope to get across is that ending road crashes and their resulting injuries and fatalities worldwide will require a cultural shift, and that shift must begin with young people, who are more likely to die in a motor vehicle crash than any other age group. More people between the ages of 15 and 29 lose their lives in crashes than from HIV/AIDS, malaria, tuberculosis, and homicide combined. GYTSM is a time to encourage this demographic to take the mantel and fight to change those statistics.

To learn more about our work in support of Global Youth Traffic Safety Month read some of our past NTSB blog posts https://safetycompass.wordpress.com/?s=global+youth+traffic+safety+month.

Would you like to add your voice to the conversation happening this week around Global Road Safety Week?  Join the Youth For Road Safety global youth Twitter chat on Friday, May 10, 2019, from 15:00–16:00 GMT (10:00–11:00 EST), follow @Yours_YforRS and use the hashtag #SpeakUpForRoadSafety.

 

 

Drink or Drive—Pick One

By Member Jennifer Homendy

The United States continues to be one of the world’s leaders in drunk-driving deaths. One of the reasons for this shameful distinction is that US drivers are allowed to operate motor vehicles with more alcohol in their system than is permitted in most other countries.

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One state in the nation is an exception to this rule: Utah, which became the first state to lower the threshold for drunk driving from .08 percent blood alcohol concentration (BAC) to .05 percent BAC, joining more than 100 countries that have a limit of .05 percent or lower. In 1983, Utah was also the first state to lead the nation in lowering the threshold from .10 percent to .08 percent BAC.

Currently, California and Michigan legislators are considering whether to adopt a .05‑percent law that will save hundreds of lives and prevent thousands of life-altering injuries over the coming years. On April 3, NTSB Safety Advocate Leah Walton added her voice to the growing chorus calling for a lower BAC limit in California, for the same reasons that I spoke in favor of a similar law in Michigan on March 20, and for the same reasons that the NTSB advocated in support of Utah’s .05 law, which went into effect December 30, 2018. (New York is also considering such a move.) All three laws satisfy our 2013 safety recommendation to lower the legal BAC limit to .05 percent or lower. All three laws will separate drinking from driving, and, by doing so, all three laws will save lives.

Our .05-percent BAC limit safety recommendation was adopted in our safety study, Reaching Zero: Actions to Eliminate Alcohol-Impaired Driving. Numerous other studies, including a recent study by the National Academy of Sciences, have reached the same conclusion: .05‑percent limits save lives.

Let me be clear: we aren’t trying to stop people from drinking; we’re working to stop people from drinking and driving. Our goal is to save lives, and our concerns are justified. In the past 10 years, more than 100,000 people have died in alcohol-involved crashes in the United States.  According to the National Highway Traffic Safety Administration, 10,874 people died in driving-under-the-influence crashes in 2017, the last full year on record. Clearly, .08-percent limits just aren’t working.

Reducing the legal BAC limit for driving is a broad deterrent that lowers the incidence of crashes and crash deaths at all BAC levels, not just those in the narrow range between .05 and .079 percent. It’s estimated that lowering the legal BAC limit in every state would likely reduce the number of fatal alcohol-related crashes by 11 percent, potentially saving up to 1,790 lives a year.

Other safety organizations have done their own great work in support of a .05-percent or lower BAC limit. The World Health Organization; the National Academies of Sciences, Engineering and Medicine; Advocates for Auto and Highway Safety; the National Safety Council; and Mothers Against Drunk Driving have all supported our safety recommendation. A .05-percent BAC limit is also supported by a majority of US motorists—63 percent, in fact, according to the AAA 2015 Traffic Safety Culture Index.

It’s noteworthy that even countries with higher alcohol consumption per capita than the United States set their BAC limits at .05 percent or lower. It’s not that people in these countries don’t drink; they just don’t drink and drive.

Growing up, my parents taught me not to drink and drive. It was just that simple. I never once heard anyone tell me it was OK to “only drive a little drunk.” My parents never lectured me that I could drink and drive as long as I kept my BAC below a certain limit.

And that’s the goal of the .05-percent movement—separating drinking from driving. You can drink responsibly. You can drive responsibly. But no one can responsibly drink and drive.

Our goal is not to propose a new target number of drinks to have before driving; rather, it’s for people to plan to either drink or drive. But never to do both.